Dermatology

By

Katrice L. Herndon, MD

Internal Medicine/Pediatrics

June 2, 2005

What is this?

Acne Vulgaris

• Acne is a self-limited disorder primarily of teenagers & young adults.

• Acne is a disease of pilosebaceous follicles.

• 4 factors are involved:• Retention hyperkeratosis

• Increased Sebum production

• Propionbacterium acnes within the follicle

• Inflammation

Acne Vulgaris• External Factors that contribute to Acne

• Oils, greases, dyes in hair products

• Detergents, soaps, astringents

• Occlusive clothing: turtlenecks, bra straps

• Environmental Factors: Humidity & Heavy exercise.

• Psychological stress

• Diet is controversial

Acne Vulgaris

• Acne vulgaris typically affects those areas of the body that have the greatest number of sebaceous glands: • the face, neck, chest, upper back, and upper arms.

• In addition to the typical lesions of acne vulgaris, scarring and hyperpigmentation can also occur.

• Hyperpigmentation is most common in patients with dark complexions

•

Acne Vulgaris• Classification of Acne

• Type 1 — Mainly comedones with an occasional small inflamed papule or pustule; no scarring present

Type 2 — Comedones and more numerous papules and pustules (mainly facial); mild scarring

Type 3 — Numerous comedones, papules, and pustules, spreading to the back, chest, and shoulders, with an occasional cyst or nodule; moderate scarring

Type 4 — Numerous large cysts on the face, neck, and upper trunk; severe scarring

Acne Vulgaris

What is this?

Acne Rosacea• Rosacea is an acneiform disorder of middle-aged and

older adults.

• Characterized by vascular dilation of the central face, including the nose, cheek, eyelids, and forehead.

• The cause of vascular dilatation in rosacea is unknown.

• The disease is chronic.

Acne Rosacea

• rosacea is a chronic disorder characterized by periods of exacerbation and remission.

• Increased susceptibility to recurrent flushing reactions that may be provoked by a variety of stimuli including hot or spicy foods, drinking alcohol, temperature extremes, and emotional reactions.

• The earliest stage of rosacea is characterized by facial

erythema and telangiectasias.

Acne Rosacea• Patients with rosacea may develop severe

sebaceous gland growth that is accompanied by papules, pustules, cysts, and nodules.

• The diagnosis of rosacea is based upon clinical findings(1 or more of the following):• Flushing (transient erythema)

• Non-transient erythema

• Papules and pustules

• Telangiectasia

Acne Rosacea• Topical antibiotics or benzoyl peroxide are the

initial treatments of choice.

• Tretinoin cream is used in patients with papular or pustular lesions that are unresponsive to other treatments.

• The chronicity of rosacea requires that medical therapy be continued long-term, not just for flare-ups of the condition.

What is This?

Allergic Contact Dermatitis

• Contact dermatitis refers to any dermatitis arising from direct skin exposure to a substance. It can be allergic or irritant-induced.

• An allergen induces an immune response, while an irritant directly damages the skin.

Allergic Contact Dermatitis• The most common sensitizer in North America is the plant

oleoresin urushiol found in poison ivy, poison oak, and poison sumac

• Other common sensitizers in the US:• nickel (jewelry)

• formaldehyde (clothing, nail polish),

• fragrances (perfume, cosmetics),

• preservatives (topical medications, cosmetics),

• rubber

• chemicals in shoes (both leather and synthetic)

Allergic Contact Dermatitis

• Treatment• Avoidance of exposure to the offending

substance.

• Use of corticosteroids topical or oral in the acute phase of the reaction maybe helpful.

• Cooling of the skin by using calamine lotion or aluminum acetate

What is this?

Psoriasis

• Psoriasis is a common chronic skin disorder typically characterized by erythematous papules and plaques with a silver scale.

• Most of the clinical features of psoriasis develop as a secondary response triggered by T-lymphocytes in the skin.

Psoriasis• Several clinical types of psoriasis have been described:

• Plaque psoriasis - symmetrically distributed plaques involving the scalp, extensor elbows, knees, and back.

• Guttate psoriasis - abrupt appearance of multiple small psoriatic lesions.

• Pustular psoriasis - most severe form of psoriasis. Characterized by erythema, scaling, and sheets of superficial pustules with erosions.

• Inverse psoriasis - refers to a presentation involving the intertriginous areas.

Psoriasis

• Nail psoriasis -the typical nail abnormality in psoriasis is pitting w/ color changes & crumbling of the nail.

Psoriasis

Psoriasis

• Most patients w/ psoriasis tend to have the disease for life.

• There is variability in the severity of the disease overtime w/ complete remission in 25% of cases.

• The diagnosis of psoriasis is made by physical examination and in some cases skin biopsy.

PsoriasisTreatment• Treatment modalities are chosen on the basis of

disease severity.• Topical emmollients, topical Steroids, tar

• Calcipotriene(Dovonex) affects the growth and differentiation of keratinocytes via its action at the level of vitamin D receptors in the epidermis.

• Tazarotene, is a topical retinoid, systemic retinoids

• Methotrexate, cyclosporine

• Immunmodulator therapy (embrel, remicade)

• Ultraviolet light.

What is this?

Vitiligo• Vitiligo is an acquired skin depigmentation that affects all

races but is far more disfiguring in blacks.

• The precise cause of vitiligo is unknown Genetic factors appear to play a role.

• 20-30 percent of patients may have a family history of the disorder.

• The pathogenesis is thought to involve an autoimmune process directed against melanocytes.

Vitiligo• Peaks in the second and third decades.

• The depigmentation has a predilection for acral areas and around body orifices (eg, mouth, eyes, nose, anus).

• The course usually is slowly progressive.

• The diagnosis of vitiligo is based upon the clinical presence of depigmented patches of skin

Vitiligo

• Repigmentation therapies include:• corticosteroids

• calcineurin inhibitors

• Ultraviolet light

• Pseudocatalase cream

• Surgery – minigrafting techiniques

• Depigmentation therapy w/ hydroquinone

What is this?

Pityriasis Rosea• Pityriasis rosea is an acute, self-limited,

exanthematous skin disease characterized by the appearance of slightly inflammatory, oval, papulosquamous lesions on the trunk & proximal areas of the extremities.

• The eruption commonly begins with a "herald" or "mother" patch, a single round or oval, rather sharply delimited pink or salmon-colored lesion on the chest, neck, or back.

• 2 to 5 cm in diameter.

Pityriasis Rosea

Pityriasis Rosea• A few days later lesions similar in appearance to the herald

patch, appear in crops on the trunk & proximal areas of the extremities.

• The eruption spreads centrifugally or from the top down in just a few days.

• The long axes of these oval lesions tend to be oriented along the lines of cleavage of the skin, like a christmas tree pattern.

• Then the lesions fade without any residual scarring.

Pityriasis Rosea

• The presence of a herald patch by history or on examination.

• The characteristic morphology and distribution of the lesions.

• The absence of symptoms other than pruritus combine to make PR an easy diagnosis in most instances.

Pityriasis Rosea

• Differential Dx include: Psoriasis, secondary syphilis, tinea corporis, Lyme disease, & drug eruptions.

• Treatment is usually reasurrance.• Topical Steroids

• Antipruitic lotions (prax, pramagel)

• Phototherapy

• Erthyromycin in severe cases

• Rash usually persists for 2-3 months

What is this?

Cellulitis• Cellulitis is an infection of the skin with

some extension into the subcutaneous tissues.

• An extremity is the most common location but any area of the body can be involved.

Cellulitis• Five factors were identified as independent

risk factors: • Lymphedema

• Site of entry (leg ulcer, toe web intertriginous, and traumatic wound)

• Venous insufficiency

• Leg edema

• Being overweight

Cellulitis

• Cellulitis is a recognizable clinical syndrome with both local & systemic features.

• Systemic symptoms include:

• Fever and chills

• Myalgias

• Increased WBC count

Cellulitis• Local findings typical of cellulitis:

• Macular erythema that is largely confluent

• Generalized swelling of the involved area

• Warmth to the touch of the involved skin

• Tenderness in the affected area

• Tender regional lymphadenopathy is common

• Lymphangitis may be present

• Abscess formation also may be present

Cellulitis

• Cellulitis in the majority of patients is caused by beta-hemolytic streptococci groups A, B, C, G, and Staphylococcus aureus.

• Other less common pathogens include H.flu, P.aeruginosa, Aermonas hydrophilia, Pasturella multocida.

Cellulitis• Diagnosis is clinical• Treatment: Anti-strep/Anti- staph

• Cefazolin• Nafcillin• Clindamycin• Vancomycin• Fluoroquinolones (3rd & 4th generations)• Macrolides (erythromycin, azithromycin)

Duration of treatment is usually 10-14 days

What is this?

Erysipelas

• Erysipelas is a characteristic form of cellulitis that affects the superficial epidermis, producing marked swelling.

• Bacterial Organisms:• Beta-hemolytic streptococci group A• Group C & G less commonly• Staph. Aureus• Streptococcus pneumoniae, enterococci, gram negative

bacilli

Erysipelas

• The erysipelas skin lesion has a raised border which is sharply demarcated from normal skin.

• This is its most unique feature and allows it to be distinguished from other types of cellulitis.

• The demarcation is sometimes seen at bony prominences.

• The affected skin is painful, edematous, intensely erythematous, and indurated (peau d'orange appearance).

Erysipelas

• The face historically was the most common area of involvement.

• Erysipelas is diagnosed clinically

• It can mimic other skin conditions:• Herpes zoster (5th cranial nerve)

• Contact Dermatitis

• Urticaria

Erysipelas

• Treatment:• Penicillin is the preferred treatment• Erythromycin• Clindamycin• Fluoroquinolones

• Erysipelas does have the propensity of recur.

What is this?

Ecthyma

• Ecthyma is an ulcerative pyoderma of the skin caused by group A beta-hemolytic streptococci.

• Because ecthyma extends into the dermis, it is often referred to as a deeper form of impetigo.

• Preexisting tissue damage (excoriations, insect bites, dermatitis) & immunocompromised states ( diabetes, neutropenia) predispose patients to the development of ecthyma.

Ecthyma• Ecthyma begins as a vesicle or pustule overlying an inflamed area

of skin that deepens into a dermal ulceration with overlying crust.• A shallow, punched-out ulceration is apparent when adherent

crust is removed.

• The deep dermal ulcer has a raised and indurated surrounding margin.

• Ecthyma lesions can remain fixed in size or can progressively enlarge to 0.5-3 cm in diameter.

• Ecthyma heals slowly and commonly produces a scar.

• Regional lymphadenopathy is common.

EcthymaTreatment:

• Topical mupirocin ointment

• Gentle surgical debridement

• Oral/IV antibiotics• Penicillin

• Clindamycin

• Macrolides

• Cefazolin

What is this?

Tinea Vesicolor

• Tinea versicolor is a common superficial infection caused by the organism Pityrosporum orbiculare.

• Which is a saprophytic yeast that is part of the normal skin flora.

Tinea Vesicolor• Lesions can be hypopigmented, light brown, or

salmon colored macules.

• A fine scale is often apparent, especially after scraping.

• Individual lesions are typically small, but frequently coalesce.

• Lesions are limited to the outermost layers of the skin.

Tinea Vesicolor• Most commonly found on the upper trunk &

extremities, & less often on the face and intertriginous areas.

• While most patients are asymptomatic, some complain of mild pruritus

• The diagnosis of tinea versicolor is confirmed by direct microscopic examination of scale with 10 % potassium hydroxide (KOH).

Tinea Vesicolor

• The differential diagnosis includes seborrhea, eczema, pityriasis rosea, and secondary syphilis.

• Treatment includes topical antifungals. Oral antifungals can be used for more extensive disease: Ketocanozole 400mg x 1 dose. Fluconazole and itraconazole are also effective.

What is this?

Cutaneous Warts

• Cutaneous warts AKA verrucae are caused by HPV which infects the epithelium of skin and mucus membranes.

• Cutaneous warts occur most commonly in children and young adults.

• Also more common among certain occupations such as handlers of meat, poultry, and fish.

• Predisposing conditions include atopic dermatitis & any condition in which there is decreased cell-mediated immunity.

Cutaneous Warts

• Infection with HPV occurs by skin-to-skin contact

• Incubation period following exposure in 2-6 months.

• Warts can have several different forms based upon location & morphology (flat, mosaic, and filiform warts)

• Lesions may occur singly, in groups, or as coalescing lesions forming plaques.

Cutaneous Warts

• The diagnosis of verrucae is based upon clinical appearance.

• Scrape off any hyperkeratotic debris & reveal thrombosed capillaries (seeds).

• The wart also will obscure normal skin markings

Cutaneous WartsDifferential Diagnosis:

• Lichen Planus• Seborrheic Keratosis• Acrochordon or skin tag

• Clavus or corn

Treatment• Spontaneous regression in 2/3 over 2yrs• Salicylic acid, liquid nitrogen, cantharidin• Cyrotherapy, curettage, laser therapy• Immunotherapy, intralesional injections

What is this?

Secondary Syphilis

• Syphilis is a chronic infection caused by the bacterium Treponema pallidum which is sexually transmitted.

• Syphilis occurs in 3 stages:• 1st stage is characterized by the classic chancre,

which is a 1-2cm ulcer with raised indurated borders, usually painless and occurs at site of innoculation. Heals spontaneously.

Secondary Syphilis

Secondary Syphilis• Secondary or systemic syphilis is characterized by a rash.

• The rash is classically a symmetric papular eruption involving the entire trunk & extremities including the palms and soles.

• Systemic symptoms include fever, headache, malaise, anorexia, sore throat, myalgias, & weight loss.

• Lymphadenopathy (inquinal, axillary)

• So-called "moth-eaten" alopecia

• Condyloma lata, grayish white lesions involving the mucus membranes

Secondary Syphilis

Secondary Syphilis

• Diagnosis at this stage is usually by serologic testing but darkfield microscopy can also be done for direct visualization of spirochete.

• Non-treponemal testing:• Veneral disease research laboratory (VDRL)• Rapid plasma reagent (RPR)

• Treponemal testing:• Fluorescent treponemal antibody absorption test• Microhemagglutination test for antibodies

Seconday SyphilisTreatment• T.Pallidum remains very sensitive to PCN.

• Long-acting benzathine penicillin G should be used.

• If documented chancre or a NR serologic testing was done in the past 1 yr, one IM dose is appropriate.

• If neither of the above applies this needs to treated as latent syphilis and 3 q week doses must be given.

• Doxycycline, erythromycin or zithromycin in pen allergic patients x 14 days.

What is this?

Herpes Zoster• Reactivation of endogenous latent VZV infection within

the sensory ganglia results in herpes zoster or "shingles", a syndrome characterized by a painful, unilateral vesicular eruption in a restricted dermatomal distribution.

• How the virus emerges from latency is not clearly understood.

• Patients frequently experience a prodrome of fever, pain, malaise and headache which precedes the vesicular dermatomal eruption by several days.

Herpes Zoster• The rash initially appears along the dermatome as

grouped vesicles or bullae which evolve into pustular or occasionally hemorrhagic lesions within three to four days.

• The thoracic and lumbar dermatomes are the most commonly involved sites of herpes zoster.

• The complications of herpes zoster include ocular, neurologic, bacterial superinfection of the skin and postherpetic neuralgia

Herpes Zoster

Treatment

• Antivirals:• Acyclovir

• Famciclovir

• Valacyclovir

• Antivirals w/ corticosteroids

• Analgesics: opioids/acetominophen

What is this?

Actinic Keratosis

• Actinic keratoses (AKs) are premalignant lesions that develop only on sun-damaged skin.

• AKs appear as patches of hyperkeratosis with some surrounding erythema on sun-exposed areas of the head and neck, forearms and hands, and upper back.

Actinic Keratosis

Actinic Keratosis• The differential diagnosis of AKs includes

seborrheic keratoses, verruca vulgaris, SCC, and superficial BCC.

• The treatment of AKs begins with prevention.• Avoiding sun exposure• sunscreens reduce the development of AKs,

• Active treatment of AKs depends upon the size of the lesion and the number of lesions present.

• Liquid Nitrogen

• Surgical curettage

• Chemotherapy (5-FU, diclofenac, imiquimod)

• Dermabrasion

• Photodynamic therapy

Which one is which?

• Basal Cell Carcinomas begins as small shiny nodules and grows slowly. It is the most common form of skin cancer.

• Frequently, the central portion breaks down to form an ulcer with a reddish-purple scab. These tumors usually remain fairly localized and rarely spread elsewhere.

• Squamous Cell Carcinoma is another common form of skin cancer. When these tumors first appear they are firm to the touch. They appear most often on sun-exposed areas of your body.

• Squamous cell carcinoma evolves very slowly through a premalignant stage known as a solar or actinic keratosis.

• Untreated, significant numbers of these lesions can metastasize to distant sites. Tumors on the lower lip and ears are at higher risk to spread.

• Malignant Melanoma is the most dangerous form of skin cancer.

• They arise from either pre-existing moles or normal skin.

• Malignant melanoma, like basal and squamous carcinomas, is linked to overexposure to the sun.

• But it can appear any place on your body.

• When detected early & with proper treatment, the recovery rate from this form of skin cancer can be very high.

References

• Harrison’s 15th Edition. Principles of Internal Medicine

• Up to Date

• Emedicine

• Dermatology Pearls Adult and Pediatric

Thank You